Morbidity and Mortality Weekly Report

Notes from the Field

Public Health Response to a Human outbreak. A World Health Organization (WHO) standardized Immunodeficiency Virus Outbreak Associated injection practices assessment tool (6) was used to interview with Unsafe Injection Practices — Roka licensed health care workers, including physicians, nurses, and Commune, , 2016 laboratory technicians, and observe all injections administered. Ugonna C. Ijeoma, MD1,2; Sin Sansam, MD3; Sok Srun, MD3; Hoy Injection technique was evaluated using a standardized check- Vannara, MD3; Sou Sanith, MD3; Tek Sopheap, MD3; Robert D. list. The interview questions ascertained knowledge, attitudes, Newman, MD2; Renuka Gadde, MBA4; Selenic Dejana, MD2; Ahmed and practices regarding injection use and safety. Frequencies 2 2 2 Saadani Hassani, MD ; Vanthy Ly, MD ; Bakary Drammeh, DrPH ; were calculated, and, given the limited sample size, exact 95% Anindya De, PhD2; Johnita Byrd, MS2; Naomi Bock, MD2 confidence intervals were estimated using statistical software. Cambodians receive 0.8–5.9 therapeutic injections per A total of 115 injection events were observed, and 39 health person per year, one of the highest reported rates worldwide care workers were interviewed (Table); 99% of injections were (1,2). Appropriate medical injections and infusions can be administered with needles and syringes taken from unopened, health sustaining or lifesaving; however, improper adminis- sterile packs. However, patient identification was not con- tration can have detrimental health consequences, including firmed before injection in 54% of events, hand hygiene pro- infectious disease transmission (3). In 2000, it was estimated cedures did not precede injection in 79% of events, and a new that worldwide, unsafe injection and waste disposal practices cotton swab was used in only 36% of events. Observation of account for 260,000 new human immunodeficiency virus safety practices demonstrated that 63% of health care workers (HIV) infections annually (3). recapped needles after use; 51% were recapped with two hands. A case-control study conducted as part of an investigation Less than half (48%) of sharps containers were appropriately of an outbreak of 242 new cases of HIV infection among resi- placed within arm’s length of health care worker; however, dents of Roka Commune, Province, Cambodia, most needles (83%) were still placed in a sharps container from December 2014 through February 2015, (4) identified immediately after use. All 39 interviewed health care workers unsafe medical injection practices by an unlicensed health care knew that HIV could be transmitted through unsafe injection practitioner as the likely source of the outbreak, highlighting practices, but fewer were aware of the potential for transmis- the potential for unsafe therapeutic injection practices to con- sion of hepatitis B virus (79%) and hepatitis C virus (62%) tribute to HIV transmission in Cambodia. After this outbreak, through this route. Finally, 28% of health care workers reported the government of Cambodia implemented new regulations ever experiencing a needle stick injury, and 49% reported ever to prohibit unlicensed medical practices (5). Although the receiving formal injection safety training. outbreak was associated with the unregulated health sector, it Although this study found little reuse of injection equipment prompted an assessment of injection safety practices among and high knowledge of the risks of unsafe injection practices licensed health care workers in Cambodia, given the high public related to HIV transmission, none of the observed injections demand for medical injections. To identify potential gaps in safe fully adhered to WHO standards of practice, thus potentially injection practices, the Cambodia Ministry of Health (MOH) compromising both patient and health care worker safety. To partnered with CDC and the medical technology company address these gaps, an intensive training curriculum on safe Becton Dickinson (Franklin Lakes, New Jersey) to conduct a injection practices for health care workers is being developed rapid assessment of injection practices at public health facilities. by Becton Dickinson with technical support from CDC. After From September 26–29, 2016, a team of medical officers review and approval by the Cambodia MOH, expert master from CDC and a clinical team from Becton Dickinson with trainers will administer this training in the same health care expertise in infection control assisted the Cambodia MOH facilities where the baseline assessment was conducted. The in implementation of the rapid assessment. A cross-sectional impact of the training on the improvement of injection and study* was conducted among the 15 main government health phlebotomy practices will be measured with a follow-up assess- care facilities in Battambang and Pursat provinces, which are ment in the same facilities where the baseline assessment was among the provinces with the highest medical injection rates conducted. Health assessment findings are also contributing (1) and are in close proximity to the site of the 2014–2015 HIV to the revision of current policies, information education and communication resources, and the development of job aids on * This study was conducted with the approval of the Cambodia National Ethics safe injection practices. Committee for Health Research.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / February 2, 2018 / Vol. 67 / No. 4 135 Morbidity and Mortality Weekly Report

TABLE. Assessment of safe injection knowledge, attitudes, and Conflict of Interest practices among health care workers — Battambang and Pursat provinces, Cambodia, 2016 No conflicts of interest were reported. Assessment component (No. assessed) No. % (95% CI) 1Epidemic Intelligence Service CDC; 2HIV Prevention Branch, Division of 3 Observation of injection administration (115) Global Health and TB, CDC; Ministry of Health, , Cambodia; 4Becton, Dickinson and Company, Franklin Lakes, New Jersey. Procedures affecting patient safety Sterile needle/syringe used for injection (112) 111 99 (95–100) Corresponding author: Ugonna Ijeoma, [email protected], 404-639-5386. Patient identification not confirmed before injection 61 54 (44–63) (113) References Hand hygiene not performed before injection 91 79 (71–86) administration (115) 1. National Institute of Statistics; Directorate General for Health; ICF Macro. Injection site cleaned with a newly moistened cotton 40 36 (27–46) Cambodia demographic and health survey 2010. Phnom Penh, Cambodia: swab (110) National Institute of Statistics, Directorate General for Health; Calverton, Procedures affecting health care worker safety MD: ICF Macro; 2011. https://dhsprogram.com/pubs/pdf/FR249/ Needle recapped after use (104) 65 63 (52–72) FR249.pdf Recapped with two hands (65) 33 51 (38–63) 2. National Institute of Statistics; Directorate General for Health; ICF Sharps container placed within arm’s reach of health 51 48 (38–58) International. Cambodia demographic and health survey 2014. Phnom care worker (106) Penh, Cambodia: National Institute of Statistics, Directorate General for Needle disposed of in sharps container immediately 91 83 (75–90) Health; Rockville, MD: ICF International; 2015. https://dhsprogram. after use (109) com/pubs/pdf/FR312/FR312.pdf Health care worker interviews (39) 3. Hauri AM, Armstrong GL, Hutin YJ. The global burden of disease Aware of disease transmission via unsafe injections attributable to contaminated injections given in health care settings. Int J Human immunodeficiency virus 39 100 (91–100) STD AIDS 2004;15:7–16. https://doi.org/10.1258/095646204322637182 Hepatitis B 31 79 (64–91) 4. Vun MC, Galang RR, Fujita M, et al.; Roka Cluster Investigation Team. Hepatitis C 24 62 (45–77) Cluster of HIV infections attributed to unsafe injection practices— Ever experienced needle-stick injury 11 28 (15–45) Cambodia, December 1, 2014–February 28, 2015. MMWR Morb Mortal Received formal training on injection safety practices 19 49 (32–65) Wkly Rep 2016;65:142–5. https://doi.org/10.15585/mmwr.mm6506a2 Abbreviation: CI = confidence interval. 5. Saphonn V, Fujita M, Samreth S, et al. Cluster of HIV infections associated with unsafe injection practices in a rural village in Cambodia. J Acquir Immune Defic Syndr 2017;75:e82–6. https://doi.org/10.1097/ Acknowledgments QAI.0000000000001295 6. World Health Organization. Revised injection safety assessment tool (tool Cambodia Provincial Health Departments, Battambang and c-revised). Geneva, Switzerland: World Health Organization; 2008. http:// Pursat; Becton Dickinson team, Franklin Lakes, New Jersey and www.who.int/infection-prevention/tools/injections/ToolC-revised.pdf Sandy, Utah; Trista Bingham, Michelle Chevalier, Gaston Djomand, Fatima Mili, Larisa Ozeryansky, Becton Dickinson Global Fellows.

136 MMWR / February 2, 2018 / Vol. 67 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention